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General NPI Number Information
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NPI Number | 1205098134
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Entity Type | Individual
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Provider Name | REBECCA S BLAKE I CNA
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Gender | Female
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Dates
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Enumeration Date | 07/01/2008
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Last Update Date | 07/22/2008
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Provider Practice Location Address
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Address Line | 408 S 17TH ST
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City | CLINTON
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State | OK
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Zip | 73601-4236
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Country | US
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Telephone | 580-323-0312
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Fax |
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Provider Business Mailing Address
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Address Line | 408 N MO ST
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City | THOMAS
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State | OK
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Zip | 73369
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Country | US
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Telephone | 580-661-2904
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 37V350170804
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 37V350170804
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License Number State | OK
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